Patterns of vestibular dysfunction in chronic traumatic brain injury (original) (raw)
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Vestibular agnosia in traumatic brain injury and its link to imbalance
Brain, 2020
Vestibular dysfunction, causing dizziness and imbalance, is a common yet poorly understood feature in patients with TBI. Damage to the inner ear, nerve, brainstem, cerebellum and cerebral hemispheres may all affect vestibular functioning, hence, a multi-level assessment—from reflex to perception—is required. In a previous report, postural instability was the commonest neurological feature in ambulating acute patients with TBI. During ward assessment, we also frequently observe a loss of vertigo sensation in patients with acute TBI, common inner ear conditions and a related vigorous vestibular-ocular reflex nystagmus, suggesting a ‘vestibular agnosia’. Patients with vestibular agnosia were also more unbalanced; however, the link between vestibular agnosia and imbalance was confounded by the presence of inner ear conditions. We investigated the brain mechanisms of imbalance in acute TBI, its link with vestibular agnosia, and potential clinical impact, by prospective laboratory assessm...
Clinical Rehabilitation, 2018
Objective: To investigate the effects of group-based vestibular rehabilitation in patients with traumatic brain injury. Design: A single-blind randomized controlled trial. Setting: University Hospital (recruitment and baseline assessments) and Metropolitan University (experimental intervention). Subjects: A total of 65 patients (45 women) with mild-to-moderate traumatic brain injury (mean age 39.4 ± 13.0 years) were randomly assigned to intervention ( n = 33) or control group ( n = 32). Intervention: Group-based vestibular rehabilitation for eight weeks. Participants were tested at baseline (3.5 ± 2.1 months after injury) and at two post-intervention follow-ups (2.7 ± 0.8 and 4.4 ± 1.0 months after baseline testing). Main measures: Primary outcome: Dizziness Handicap Inventory. Secondary outcome: High-Level Mobility Assessment Tool. Other outcomes: Vertigo Symptom Scale; Rivermead Post-concussion Symptoms Questionnaire; Hospital Anxiety and Depression Scale; and Balance Error Scorin...
International Journal of Audiology, 2020
Objective:To establish the frequency of occurrence of peripheral vestibular dysfunction in adults who have sustained non-blast-related traumatic brain injury (TBI) as measured through the standard audiological vestibular test battery. Design: A systematic search of English language literature using MEDLINE, EMBASE, PsycINFO, CINAHL, hand-searching of reference lists and SCOPUS author search was conducted from January 1, 1990 to May 14, 2019. Study samples: Twenty-three out of 417 originally identified articles were retained. TBI and peripheral vestibular findings were extracted and synthesised. Results: Quality appraisal using the Oxford Centre for Evidence-Based Medicine (OCEBM) revealed Level 2b as the highest level of evidence. None of the primary studies explored vestibular deficits in acute settings, with data collected from tertiary institutions and in 20 of 23 studies retrospectively. Although retrospective studies provided important data, they fail to control for numerous threats to internal validity. BPPV was the most frequently identified peripheral vestibular deficit following TBI, diagnosed in 39.7% of 239 participants across six of 23 studies. Conclusions: Further prospective longitudinal research into comparative recovery trajectories in patients across TBI severity levels would provide additional information to guide clinical diagnosis, prognosis and management of this patient population.
Vestibular pathology has been documented following barotrauma and/or head acceleration associated with exposure to explosions. The usual symptoms include dizziness and headache, with dizziness and associated imbalance contributing disproportionately to disability. Several agencies have noted the need for better vestibular evaluation and rehabilitation following exposure to improvised explosive devices (IEDs). The authors asked subject matter experts to assist in formulating recommendations for initial assessment and rehabilitation of balance problems following IED exposure, focusing on strategies that are either available or in development. This report summarizes feedback obtained from approximately 50 vestibular researchers, scientific advisors, clinicians, and biomedical engineers working for government agencies, universities, clinics/hospitals, and businesses. Tests appropriate for early (post-injury) functional assessment in the military setting are considered, along with the optimal application of novel tactile balance feedback technologies being developed to augment vestibular rehabilitation.
Vestibular and balance issues following sport-related concussion
Brain Injury, 2015
Primary objective: To review relevant literature regarding the effect of concussion on vestibular function, impairments, assessments and management strategies. Reasoning: Dizziness and balance impairments are common following sport-related concussion. Recommendations regarding the management of sport-related concussion suggest including tests of balance within the multifactorial assessment paradigm for concussive injuries. Analysis: The literature was searched for guidelines and original studies related to vestibular impairments following concussion, oculomotor and balance assessments and treatment or rehabilitation of vestibular impairments. The databases searched included Medline, CINAHL, Sport Discus and the Cochrane Database of Systematic Reviews through October 2013. Main outcomes and results: Dizziness following concussion occurs in $67-77% of cases and has been implicated as a risk factor for a prolonged recovery. Balance impairments also occur after concussion and last 3-10 days post-injury. Assessments of balance can be done using both clinical and instrumented measures with success. Vestibular rehabilitation has been shown to improve outcomes in patients with vestibular impairments, with one study demonstrating success in decreasing symptoms and increasing function following concussion. Conclusions: Best practices suggest that the assessment of vestibular function through cranial nerve, oculomotor and balance assessments are an important aspect of concussion management. Future studies should evaluate the effectiveness of vestibular rehabilitation for improving patient outcomes.
Injurious motion and/or ambient pressure changes to the head are caused by vehicle-related accelerations, impacts, and vibrations, as well as explosions, barotraumas, and job-related or recreational falls or head injuries. Such injuries occur during land, sea, and air operations. Precipitous changes in head velocity or ambient pressure cause concussion, traumatic brain injury (TBI), whiplash, and/or vestibulocochlear injury. Associated signs and symptoms include fatigue, headache, dizziness, vertigo, imbalance, disorientation, poor gaze control, and cognitive effects. This paper considers the vestibular implications of head injury. The vestibular system controls balance and gaze – functions which are critical to human sensorimotor activity and most military missions. The vestibulocochlear end organ is exquisitely sensitive to sudden changes in velocity or pressure, a fact underscored by a recent study which found evidence of vestibular pathology in most of the mild TBI (MTBI) cases suffered by a sample of military personnel who had served in Operation Iraqi Freedom (OIF). This paper reviews the evidence for a relation between head acceleration/pressure and vestibular injury/dysfunction and argues that assessment of vestibular function is important following exposure to such insults. This paper briefly describes the rationale for a few candidate vestibular tests which would augment existing evaluations and aid return-to-duty decisions following head injury. The tests that are introduced include dynamic posturography, dynamic visual acuity, subjective visual vertical, and vestibular evoked myogenic reflex function. Tests such as these are recommended for mild TBI patients who have been exposed to improvised explosive devices (IEDs). Additionally, better balance rehabilitation tools are recommended. This paper briefly describes the rationale for a biofeedback device which provides tactile sway feedback to augment physical therapy (PT). The prototype will be developed and tested to determine if it fosters more rapid or complete recovery of balance following TBI.
2014
Background: It is well established that vestibular injury can occur with traumatic brain injury (TBI). Symptoms that could be related to vestibular dysfunction rather than a brain injury include vertigo, dizziness, and imbalance. Reports indicate that the incidence of dizziness or imbalance secondary to vestibular dysfunction may occur in up to 83% of adults following mild TBI but there are few studies examining this in children. It is difficult, but clinically very relevant, to differentiate symptoms due to vestibular injury as the treatment is very different. Objective: 1) To examine the symptom of dizziness in children with TBI and 2) Investigate the prevalence of vestibular dysfunction in children following a TBI using a novel diagnostic technique. Methods: Prospective cohort study. Population: Children aged 11-18 years with a) mild TBI presenting to the Emergency Department (ED) (acute/subacute); and b) mild to severe TBI symptomatic ≥1 month post-injury (chronic). Outcome mea...
Journal of Head Trauma Rehabilitation, 2019
; and the Chronic Effects of Neurotrauma Consortium Objective: To describe the prevalence and impact of vestibular dysfunction and nonspecific dizziness diagnoses and explore their associations with traumatic brain injury (TBI) severity, mechanism, and postconcussive comorbidities among post-9/11 veterans. Setting: Administrative medical record data from the US Departments of Defense and Veterans Affairs (VA). Participants: Post-9/11 veterans with at least 3 years of VA care. Design: Cross-sectional, retrospective, observational study. Main Measures: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for TBI, vestibular dysfunction, dizziness, and other commonly associated postconcussive conditions; Neurobehavioral Symptom Inventory. Results: Of the 570 248 post-9/11 veterans in this sample, 0.45% had a diagnosis of vestibular dysfunction and 2.57% had nonspecific dizziness. Those with either condition were more likely to have evidence of TBI (57.11% vs 28.51%) and reported more disruption from neurobehavioral symptoms. Blast and nonblast injuries were associated with greater symptom disruption, particularly in combination. Conclusions: There was a consistent, significant association between TBI and vestibular dysfunction or nonspecific dizziness, after controlling for sociodemographic factors, injury mechanism, and comorbid conditions. Given that most deployed post-9/11 veterans report blast and/or nonblast injuries, the need for prompt identification and management of these conditions and symptoms is clear.
Journal of Head Trauma Rehabilitation, 2019
To estimate the frequency of vestibular dysfunction following blunt, blast, and combined blunt and blast mild traumatic brain injury (mTBI) and thereon assess the long-term impact of vestibular dysfunction on neurobehavioral function and disability independently of comorbid psychiatric symptoms. Setting: Combat Stress residential and Veterans' Outreach drop-in centers for psychological support. Participants: One hundred sixtytwo help-seeking UK military veterans. Main Measures: Self-reported frequency and severity of mTBI (using the Ohio State TBI Identification Method), Vertigo Symptom Scale, PTSD Checklist for DSM-5, Kessler Psychological Distress Scale (K10), Neurobehavioral Symptom Inventory, Headache Impact Test (HIT6), Memory Complaints Inventory, World Health Organization Disability Assessment Schedule II short version (WHODAS 2.0). Results: Seventy-two percent of the sample reported 1 or more mTBIs over their lifetime. Chi-square analyses indicated that vestibular disturbance, which affected 69% of participants, was equally prevalent following blunt (59%) or blast (47%) injury and most prevalent following blunt and blast combined (83%). Mediation analysis indicated that when posttraumatic stress disorder, depression, and anxiety were taken into account, vestibular dysfunction in participants with mTBI was directly and independently associated with increased postconcussive symptoms and functional disability. Conclusion: Vestibular dysfunction is common after combined blunt and blast mTBI and singularly predictive of poor long-term mental health. From a treatment perspective, vestibular rehabilitation may provide relief from postconcussive symptoms other than dizziness and imbalance.
Vestibular, Oculomotor, and Balance Functions in Children With and Without Concussion
Journal of Head Trauma Rehabilitation, 2021
The main objective of this study was to assess whether objective vestibular, oculomotor, and balance functions were impaired in children with a current diagnosis of concussion with vestibular and/or ocular symptoms. SETTING: Data was collected in a vestibular/ocular clinical lab. Patient participants were recruited from a concussion clinic in a children's hospital. PARTICIPANTS: 33 children ages 8-17 with a current diagnosis of concussion and vestibular and/or ocular symptoms and 30 children without concussion. DESIGN: Cross-sectional single visit study. MAIN OUTCOME MEASURES: Eye-tracking rotary chair oculomotor and vestibular measures, vestibular evoked potentials, and static posturography. RESULTS: There were no statistically significant differences on any clinical measure between children with concussion and children without concussion. Younger children without concussion performed significantly worse on several rotary chair and balance measures compared to older children without concussion. CONCLUSIONS: No vestibular, oculomotor, or balance measures were significantly different between children with concussion and children without concussion, suggesting these measures